ACUTE HYPOXIA/SOB
Questions to ask the nurse:
1. What are the patient’s vital signs? How much 02 are they on and what is the 02 sat?
2. What is the reason for admission?
3. When was the onset of SOB?
4. What is the quick history? Does the patient have asthma, COPD?
Things to order before you even get the bedside:
1. O2
2. CXR
3. ABG kit with ice
4. Respiratory tech to standby for nebs, non-rebreather, etc…
5. EKG
6. Cardiac Enzymes
7. D-Dimer
8. BNP
Think of a differential on the way to the bedside:
1. Asthma exacerbation
2. COPD exacerbation
3. Myocardial Infarction
4. Pulmonary Edema secondary to acute CHF
5. Panic attack
6. Narcotic or benzodiazepine overdose
Things on your differential you absolutely do not want to miss and MAKE SURE TO RULE OUT ASAP:
1. Pulmonary Embolism
2. Pneumothorax
3. Tamponade
4. Acute myocardial infarction with rupture off papillary muscle…leads to severe, acute pulmonary edema secondary to CHF
5. Obstruction
When you get to the bedside:
1. Check the vitals again…feel the pulse, count the respiratory rate, check the O2 sat and temperature…check for a pulsus paradoxus if tamponade is suspected…check the neck veins for JVD…look for peripheral (fingers) and central (tongue) cyanosis…is the patient mentating, can they protect their airway, if not, YOU MUST CALL ANESTHESIA FOR POSSIBLE INTUBATION…determine at this point if you need to call THE ICU RESIDENT.
2. Listen to the lungs bilaterally in all fields
3. Check the trachea, make sure it is midline…be careful not to miss Pneumothorax.
4. Check the oropharynx, look for any obvious obstrustion
3. Listen to the heart…listen for new, harsh murmur…pericardial rub
4. Review the chart very quickly…has this patient received a lot of narcotics or benzodiazepines…then you need to get naloxone or flumazenil stat and administer.
5. Do your ABG and have it sent STAT
6. Review a 12-lead EKG at the bedside
Stabilize the patient:
1. Deliver O2, get the sats >92%
2. Suction the patient if there are secretions
3. Do you hear crackles? Is there JVD? Then you need to raise the head of the bed and give them Lasix IV stat.
4. Do you hear a pericardial rub? Is there JVD? Do they have pulsus paradoxus? Is there electrical alternans? Then you need to get a STAT 2-D ECHO to eval for Tamponade and call Cardiology, this person may need PERICARDIOCENTESIS.
5. Is the trachea shifted? Are there absent breath sounds? Then you need a STAT CXR and call Pulmonary, this person may need them or yourself to place a CHEST TUBE STAT…remember, 2nd intercostal space, mid-clavicular line.
6. Do you hear wheezing? Then you need Nebulizer treatments STAT, you may to get IV steroids on board as well.
7. Has this patient received a lot of narcotics or benzodiazepines? Then you need to get NALOXONE or FLUMAZENIL STAT.
Evaluate the tests you have ordered after you have stabilized the patient:
1. ABG…pH low, high or normal CO2, low 02 sat…you must now rule-out PULMONARY EMBOLISM with a CT-PE PROTOCOL STAT. If the pH is less than 7.20 and does not improve with your quick treatments, you need to call anesthesia…they will likely need intubation.
2. ECG…look for any ST-SEGMENT changes indicative of MI, look for ELECTRICAL ALTERNANS indicative of TAMPONADE, look for signs of RIGHT HEART STRAIN indicative of PE.
3. CXR…DO NOT MISS PNEUMOTHORAX.
4. OTHER LAB TESTS…check the Cardiac Enzymes…check the D-Dimer…check the BNP.